Nursing Diagnosis: Adult Failure to thrive with NANDA, NOC, NIC

Nursing
Diagnosis: Adult Failure to thriveGail B. Ladwig

NANDA Definition:
Progressive functional deterioration of a physical and cognitive nature with
remarkably diminished ability to live with multisystem diseases, cope with
ensuing problems, and manage care

Defining
Characteristics: Anorexia-does not eat meals when offered;
states does not have an appetite, is not hungry, or "I don't want to
eat"; inadequate nutritional intake-eating less than body requirements;
consumption of minimal to no food at most meals (i.e., consumes less than 75%
of normal requirements); weight loss (from baseline weight)-5% unintentional
weight loss in 1 month or 10% unintentional weight loss in 6 months; physical
decline (decline in bodily function) — evidence of fatigue, dehydration,
incontinence of bowel and bladder; frequent exacerbations of chronic health
problems (e.g. pneumonia, urinary tract infections); cognitive decline (decline
in mental processing) as evidenced by problems with responding appropriately to
environmental stimuli, demonstrated difficulty in reasoning, decision making,
judgment, memory, and concentration; decreased perception; decreased social
skills; social withdrawal-noticeable decrease from usual past behavior in
attempts to form or participate in cooperative and interdependent relationships
(e.g., decreased verbal communication with staff, family, friends); decreased
participation in ADLs that the older person once enjoyed; self-care deficit-no
longer looks after or takes charge of physical cleanliness or appearance;
difficulty performing simple self-care tasks; neglect of home environment
and/or financial responsibilities; apathy as evidenced by lack of observable
feeling or emotion in terms of normal ADLs and environment; altered mood
state-expresses feelings of sadness, being low in spirit; expresses loss of
interest in pleasurable outlets such as food, sex, work, friends, family,
hobbies, or entertainment; verbalizes desire for death

Related Factors:
Depression; apathy; fatigue

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·Physical
Aging Status

·Psychosocial
Adjustment: Life Change

·Will
to Live

Client Outcomes

·Resumes
highest level of functioning possible

·Consumes
adequate dietary intake for weight and height

·Maintains
usual weight

·Has
adequate fluid intake with no signs of dehydration

·Participates
in ADLs

·Participates
in social interactions

·Maintains
clean personal and home environment

·Expresses
feelings associated with losses

NIC Interventions (Nursing
Interventions Classification)

Suggested NIC Labels

·Mood
Management

·Self-Care
Assistance

Nursing Interventions and
Rationales

·Elderly
clients who have failure to thrive (FTT) should be evaluated by review of the
patient's ADLs, cognitive function, and mood; a targeted history and physical
examination; and selected laboratory studies. Early recognition and management of FTT can reduce the
risk of further functional deterioration, hospitalization, or nursing home
placement (Palmer, Foley, 1990).

·Assess
possible causes for adult FTT and treat any underlying problems such as
depression, malnutrition, and illnesses that are caused by physical and
cognitive changes. The
characteristics of FTT in the elderly are malnutrition (undernutrition), loss
of physical and cognitive function, and depression (Groom, 1993). Malnutrition
is a frequent condition, both widely represented in the geriatric population
and underestimated in diagnostic and therapeutic work-up, and is known to
affect health status and life expectancy of elderly people (Vetta et al, 1999).
An initial clinical assessment that combines multiple and varied sources of
information is recommended to evaluate patients with suspected dementia (U.S. Department
of Health and Human Services, 1996).

·Assess
for signs of fatigue and sensory changes that may indicate an infection is
present that may be related to undetected diabetes mellitus. Older adults may never exhibit the
classic signs of polyuria, polydipsia, polyphagia, and weight loss; instead
they may develop an infection and complain of fatigue and sensory changes
(Faherty, 1994).

·Assess
for all etiologies including depression using a geriatric depression scale. Be
alert for depression in clients newly admitted to nursing homes. The geriatric depressions scale is
recommended to determine the presence of depression (Jamison, 1997). Depression
in newly admitted nursing home residents is a frequently overlooked area of
nursing concern (Ryden et al, 1998). New depression may be the first sign of
impending cognitive dysfunction (Sarkisian, Lachs, 1996).

·Note
if the client is irritable and is blaming others. Recent findings in nursing research support the
presence of these behaviors as symptomatic of depression (Proffitt, Augspurger,
Byrne, 1996).

·Provide
cognitive therapy for clients who are identified as depressed. Reinforce their
value as a person and provide reality as to "who they really are." Clients who are depressed can be
helped by examining "who they are" as compared to "who they
believe they are" (Drake, Price, Drake, 1996).

·Instill
hope and encourage the expression of positive thoughts. The findings from this study of 1002
older disabled women suggest that positive emotions can protect older persons
against adverse health outcomes. Of the women studied, 351 were described as
emotionally vital, and among the women without a specific disability at
baseline, emotional vitality was associated with a significantly decreased risk
for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident
disability walking 1/4 mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident
disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95).
Emotional vitality was also associated with a lower risk of dying (RR = 0.56,
95% CI = 0.39-0.80). These results were not simply caused by the absence of
depression because protective health effects remained when emotionally vital
women were compared with 334 women who were not emotionally vital and not
depressed (Pennix et al, 2000).

·Monitor
elderly client's weight and note any unexplained weight loss. The FTT of an elderly client is
usually accompanied by weight loss that occurs without immediate explanation
(Palmer, Foley, 1993).

·Play
soothing music during mealtimes to increase the amount of food eaten. One study suggested that dinner
music, particularly soothing music, can reduce irritability, fear, panic, and
depressed mood and can stimulate the appetite of demented patients in a nursing
home. In this study the patients were less irritable, anxious, and depressed
during the periods when music was playing (Ragneskog et al, 1996).

·Note
changes in the elderly client's appetite and assess for depression. Depression can lead to FTT by two
routes: a direct path of decreased appetite as a symptom of depression and an
indirect path of increasing disability as an effect of depression (Katz,
DiFilippo, 1997).

·Offer
comfort foods and happy hour: foods associated with bygone years, intended to
trigger recollections of pleasant childhood experiences and feelings of caring
and healing, and a "happy hour" beverage, presented in a social
milieu. These are two approaches
that have demonstrated effectiveness in stimulating oral intake in the FTT
client (Wood, Vogen, 1998).

·Provide
appropriate nutrition for the client whose obesity may be affecting physical
performance and thus has limited ability to perform ADLs, which leads to
functional dependence. Malnutrition
includes obesity (overnutrition); obesity among older persons is defined as
being (30% above ideal body weight. Obesity may contribute to the previously
mentioned problems (Still, Apovian, Jensen, 1997).

·Encourage
clients to pray if they wish. Various
studies have discovered that various groups of people have used prayer for
managing their symptoms of aging or illness (Meraviglia, 1999).

·Encourage
elderly clients to interact with others on a regular basis. Have them
participate in activities for seniors in their community. FTT of an elderly client is usually
accompanied by social withdrawal (Palmer, Foley, 1993).

·Help
clients to participate in activities by assessing motivation and helping them
to identify reasons to participate such as better mobility, more independence,
feelings of well-being. Motivation
has been identified as an important factor in the older adult's ability to
perform functional activities (Resnick, 1998).

·Administer
therapeutic touch (TT). Results
of this study of (n = 16) patients in the advanced stages of dementia of the
Alzheimer's type (DAT), showed that discomfort levels decreased significantly
after five therapeutic touch sessions, becoming significantly lower than levels
in the control group (n = 10) (Giasson et al, 1999).

·Refer
to care plans for Imbalanced
Nutrition: less than body requirements, Hopelessness, and Disturbed Energy field.

Multicultural

·Assess
for the influence of cultural beliefs, norms, and values on the family's or
caregiver's understanding of FTT. What
the family considers normal and abnormal health behavior may be based on
cultural perceptions (Leininger, 1996).

·Validate
the family's feelings and concerns related to the FTT symptoms. Validation lets the family know that
the nurse has heard and understands what was said, and it promotes the
nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

·Assess
and track areas of decreased functioning resulting from failure to thrive.
Ensure that all symptomatology is considered for necessary action. Clients may change response to
stressors/needs with changes in environment or interventions.

·Give
permission for role activity changes. Negotiate and clarify role expectations and
reevaluate as necessary. Failure
to thrive may require an extended period of recovery. Chronic illness often
requires role changes to preserve a functional unit. Comfort level with role
activities supports continued recovery.

·Provide
support for family/caregivers. Support
for caregivers decreases caregiver burden.

·Refer
to medical social services or mental health counseling and/or community support
groups. If necessary, contract with client to attend sessions. Counseling support can increase
coping ability; group participation provides support and offers new
problem-solving strategies to the client.

·Refer
to home health aide services for assistance with ADLs throughout the duration
of decreased participation. Maintaining
ADLs and the integrity of the environment prevents further decline in status of
those areas and decreases frustration as the client recovers and resumes
responsibility for them.

Client/Family Teaching

·If
adult FTT is related to dementia, help the caregiver to understand the
diagnosis and help to identify needs that the caregiver will have to assist
client with, such as nutrition, maintenance of adequate fluid intake,
toileting, self-care, and safety. When
the etiology of adult FTT is dementia, the caregiver needs to be educated on
how to handle (Jamison, 1997).

·Instruct
the family on the use of verbal cues to encourage eating, such as "Pick up
your spoon; use the spoon to scoop up the pudding; now put the spoon with the
pudding in your mouth." Verbal
cueing is effective for improving nutritional status (Jamison, 1997).

·Discuss
the possibility with the physician of a drug holiday when the etiology is
delirium. Delirium may
resolve with a drug holiday (Jamison, 1997).

·Provide
referral for evaluation of hearing and appropriate hearing aids. This study of 60 subjects >65
years of age (mean age 79 years) living in nursing homes demonstrated that
hearing loss affects the communication, sociability, and psychological aspects
of quality of life (Tsuruoka et al, 2001).

·Refer
for psychotherapy and possible medication if the etiology is depression. Treatment of the etiology is
necessary; the previously mentioned are treatments that may be used for
depression (Jamison, 1997).